Therapeutic Communities (TCs)
These programs are another approach that has been shown to be useful for treating opioid dependence, especially patients with a long history of addiction and a strong motivation to become drug-free, either as a result of internal processes or from external pressures such as being given the choice of entering prison for a drug-related crime, or getting treatment in a TC. These programs are very selective, self-governing and long-term (6–18 months). They occur in residential settings where patients share responsi-bilities for maintaining the treatment milieu (cleaning, cooking and leading group therapy). Confrontation of denial and behav-iors such as lying and “conning”, combined with group support for healthy, positive change are used to restructure character and the addictive lifestyle. Medications such as methadone, LAAM, or naltrexone are rarely used; however, medications for specific psychiatric or medical conditions are usually available after care-ful screening and evaluation. Many TCs have large numbers of individuals who have been referred by the criminal justice sys-tem including some who have tried but not responded to agonist maintenance on repeated occasions. Though dropout rates are high, studies have shown that over 80% of individuals who com-plete TCs have a sustained remission and demonstrate significant improvement in psychiatric symptoms, employment and crimi-nal behavior (Inciardi et al., 1997; DeLeon, 1999)
Patients seeking treatment for opioid dependence are typically using one or more other substances (cocaine, alcohol, benzodi-azepines, amphetamines, marijuana, nicotine), and have addi-tional problems in the psychiatric, medical, family/social, em-ployment, or legal areas. In fact, it is rare to find a person with only opioid dependence and no other substance use, or without a psychiatric, medical, or family/social problem. The presence of these problems, perhaps with the exception of nicotine depend-ence, tends to magnify the severity of the opioid dependence and makes the patient even more difficult to treat.